The business of mental health and addiction treatment is continually evolving. Here, we shine a light on five trends in the mental health and substance use disorder (SUD) space, from insurance company challenges to developing therapeutic methodologies.
Payor Pressure
Many private insurance companies (payors), which provide customers with health plans that offer cost coverage and reimbursements for SUD treatment and care services, are now required to align treatment and payment policies with American Society of Addiction Medicine (ASAM) or equivalent industry guidance. This has led to some more reasonable requirements for providers. Nevertheless, payors are still conducting medical record audits, placing providers in SIU or pre-payment review, and often delaying or denying payment on legitimate claims.
For their part, SUD providers must be diligent about tracking all hours of services provided, including specifying the individuals providing those services and making sure they are qualified to do so. This is especially important because some payors are using minor documentation discrepancies as a basis to deny payment for an entire day, or even an entire week, of treatment—an outcome that can create conflicts with clients.
Some payors are also using improper guidelines as a basis for denying payment, including inconsistent standards applied by different auditors even within the same payor organization. Providers need to get ahead of these issues, ideally before they get audited. If providers are sent to SIU or pre-payment review, they should act immediately and aggressively to avoid payment denials and delays that can have a devastating financial impact on their organizations.
State Laws Regarding Advertising
Several states are enacting their own SUD industry-specific advertising restrictions. These laws generally prohibit misleading advertising, particularly as to the location, services or identity of a given provider. Others require specific credentials or licenses for advertisers. In light of the national reach of online advertising, providers must be diligent in determining what advertising rules apply to them, with an eye toward compliance with new laws as they continue to spring up across the country.
Market Expansion Combined With Overwhelmed Public Agencies
As money continues to flow into the SUD space, public agencies continue to be backlogged and overwhelmed from COVID-19-related restrictions and prioritization directives. Consequently, new facilities are facing unprecedented delays in obtaining licenses, which is creating financial burdens for providers and access to care issues for clients.
Tension Between State and Local Governments on NIMBY Laws
Over the law few years, several California cities and counties have attempted to limit the number, type, operations and size of SUD facilities and sober living/transitional living homes. Some of these restrictions are patently unconstitutional. Federal and state agencies have reiterated parity concerns and their desire to protect clients who are seeking treatment for mental health and SUD issues. While certain local governments are heeding this guidance, others are disregarding it entirely. And even cities that do not have so-called NIMBY laws on the books will nevertheless target mental health or SUD facilities with frequent unannounced visits by officials or law enforcement. Oftentimes, no citations are ever issued; instead, the goal seems to intimidate providers and their clients.
Medication Assisted Therapy
Medication Assisted Therapy continues to become more mainstream and both federal and state governments are dedicated to reducing discrimination against clients receiving this form of treatment. However, MAT can create a conflict with abstinence-based programs, as well as with sober living or transitional living homes. Although some traditionally abstinence-based providers are now incorporating MAT, others are resistant to what they consider government overreach into treatment philosophies and methodologies. By virtue of these differences in opinion, we will likely see more discourse on this topic within the recovery industry.
This blog post is not offered, and should not be relied on, as legal advice. You should consult an attorney for advice in specific situations.
